TCMP Article: Spinal stenosis — practice tips

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Author

Dr. Mark Adrian (biography, no disclosures)

What care gaps or frequently asked questions I have noticed

Degenerative lumbar spinal stenosis is a radiological finding consisting of narrowing of the spinal canal. It occurs in older adults and if symptomatic, can result in pseudoclaudication (numbness, pain, and weakness) of the lower extremities.1 Although the diagnosis is often straightforward, atypical presentations are common as are competing diagnoses. The treatment options are variable and are dependent on the patient’s goals, clinical presentation, and imaging findings.

Data that answers these questions or gaps

Degenerative changes of the spine (disc bulges, hypertrophy(enlargement) of the facet joints, and ligamentum flavum buckling) can result in narrowing of the spinal canal and compression of the spinal nerve roots, cauda equina, spinal veins, and arteries. Patients experiencing symptomatic stenosis can present with a spectrum of symptoms, ranging from minor to disabling symptoms associated with neurological deficits. Degenerative changes of the spine however are ubiquitous in older adults and the degree of stenosis on spinal imaging (even if severe) does not reliably correlate with the presence of symptoms or degree of symptoms.2

Hip arthritis, vascular disorders, and peripheral nerve dysfunction are common in the older adult and can mimic symptoms of stenosis. Non-specific lower back pain is common in general population and spinal canal narrowing is common in asymptomatic older adults. Care therefore must be taken to distinguish the source of the symptoms (Tables 1 and 2).

What I recommend (practice tips)

1. Distinguish the source of the symptoms. A detailed history and physical are required to establish the diagnosis and rule out competing disorders.
   • The cardinal historical features of symptomatic stenosis are varying degrees of lower extremity symptoms of pain, heaviness, numbness, or stiffness that are triggered by walking (or standing) and relieved by sitting or forward flexed posture (shopping cart sign).
   • Peripheral neuropathies generally present with non-positional burning symptoms in a stocking distribution.
   • Physical examination is usually benign in patients with stenosis, but evaluation of the hips, distal pulses, and reflexes is necessary to rule out competing disorders.

   Table 1. Symptoms and causes

   PSEUDOCLAUDICATION	VASCULAR CLAUDICATION
   Symptoms progress from back/buttock, distally to the lower extremities	Symptoms progress from ankle/calf to proximally
   Variable limitation of walking distance (posture dependent)	Consistent limitation of walking distance
   Climbing downstairs more symptomatic the upstairs	Climbing upstairs more symptomatic than downstairs
   Cycling/stationary bike generally well tolerated	Cycling/stationary bike exacerbate symptoms

   
   Table 2. Signs and symptoms suggesting hip joint-mediated pain

   HIP JOINT-MEDIATED PAIN

   Pain with pivoting

   Pain with transitioning (getting in and out of the car or off the sofa)

   Pain with crossing legs or putting on shoes or socks

   Limp

   Painful and limited hip internal rotation on physical exam

2. Cross-sectional imaging (MRI or CT) is required to establish the diagnosis. Although MRI and CT scans provide complementary information, MRI defines the soft tissues, thecal sac, and nerve roots better than a CT scan. If contra-indicated or not available, a CT scan (from the L2 level to the sacrum) is usually satisfactory. Symptomatic stenosis is positional and MRI and CTs are static investigations, performed supine. To better evaluate for a dynamic spinal deformity that may be contributing to the stenosis, standing spinal x-rays (AP and Lateral) are also recommended, in addition to cross-sectional imaging.
3. In the majority of cases, symptomatic spinal stenosis is a stable (or slowly progressive) condition that can be managed conservatively. Exercises that place the patient in a flexed position should be encouraged (e.g., cycling, skating, cross-country skiing, walking with walking poles, or rolling walker) and are generally tolerated. Exercise should be encouraged to maintain and optimize fitness and function. Instruction in a home exercise program by a physiotherapist in balance, postural exercises (particularly addressing thoracic kyphosis), and hip flexor and hamstring stretching can optimize the spinal biomechanics and potentially “open up” the spinal canal.
4. In some patients with radicular pain, gabapentin can be helpful.³
5. Epidural steroid injections (ESI) performed in a hospital setting or facility that uses imaging guidance can provide short-term help (3–6 months) in many patients.⁴ The degree and duration of the response to epidural injections however are unpredictable. If effective, ESIs can safely be organized on a recurring basis.
6. Referral for a surgical opinion is indicated in patients who are severely disabled with advanced spinal stenosis on imaging, or in the rare cases of rapid progression with neurological deficits, or the development of bowel or bladder dysfunction (cauda equina syndrome).⁵

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References

1. Jensen RK, Jensen TS, Koes B, Hartvigsen J. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. Eur Spine J. 2020;29(9):2143-2163. doi:10.1007/s00586-020-06339-1 (View with CPSBC or UBC)
2. Kreiner DS, Shaffer WO, Baisden JL, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013;13(7):734-743. doi:10.1016/j.spinee.2012.11.059 (View)
3. Yaksi A, Ozgönenel L, Ozgönenel B. The efficiency of gabapentin therapy in patients with lumbar spinal stenosis. Spine (Phila Pa 1976). 2007;32(9):939-942. doi:10.1097/01.brs.0000261029.29170.e6 (View with CPSBC or with UBC)
4. Cohen SP, Greuber E, Vought K, Lissin D. Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need. Clin J Pain. 2021;37(9):707-717. doi:10.1097/AJP.0000000000000963 (View)
5. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med. 2008;358(8):794-810. doi:10.1056/NEJMoa0707136 (View)

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